An Episcopal (Anglican) Chaplain in the Saint Luke's Health System of Kansas City, reflecting on work and faith and life. NOTA BENE: my opinions are my own and do not represent the Episcopal Church or the Saint Luke's Health System.

Monday, November 05, 2007

Universal Health Care: Public/Private Partnerships

After this recent post, I continued to think about the idea of public/private partnerships as ways to meet social needs. Of course, I'm especially interested in such partnerships in pursuing universal access to health care. Perhaps this is a way to reframe the debate, and to imagine new options.

Watch the news, even for a few days, and you'll realize we enter into public/private partnerships all the time. Local and state governments offer tax incentives to bring new businesses, new jobs, to underserved areas. They do so believing that greater economic activity benefits not just the company per se, but also the residents employed by the company, and then other residents with whom they do business, and, ultimately, the community as a whole. Those governments provide some financial assistance, and perhaps some infrastructure assistance, and the rest is done by private interests - the company and those they employ or contract with. Those governments forego some immediate revenue to invest in long-term benefits for the whole community.

Consider the interstate highway system: it's a classic example on a grand scale. It was originally approved by Congress as a defense measure: to better move troops and materials for defense. However, the highways weren't built by federal employees. They were built, and continue to be maintained, by private businesses contracted by federal and state governments. Government bodies establish routes and engineering standards; they coordinate with private companies to plan implementation; and the private companies manage the construction.

Public participation is important to these activities. Granted, government bodies are the source of the funds. More important, government bodies have the widest accountability. Private companies are accountable first and foremost to their owners and/or shareholders. Believing as we do in a market economy, that's appropriate. They can be held accountable by individuals; but that can take a lot of time and money spent in legal pursuit.

Government bodies, on the other hand, are accountable to all of us - at least, to all of the citizens within the constituency. They can be held accountable with each election cycle; and between election cycles by constitutional processes for recall (not to mention an attentive press). Private companies, by and large, work to do well by those they serve; but only public servants are accountable to all of the public. And, by contracting out the work, public servants can hold private companies accountable more directly, under the terms of the contract.

And make no mistake: issues of those who don't get health care, or who get health care that doesn't get paid for, do affect all of us, citizens and non-citizens alike. Whooping cough has made a resurgence in this generation. Methicillin-resistant staph aureus (MRSA), a disease once known only in immune-suppressed patients in hospitals, is now showing up in the general population and in the news. We continue to prepare for the possibility of pandemic flu. These are public health issues that put all of us at risk; and the first line of defense for all of us is making primary care available to all, an especially to those least likely to get it through employment.

And make no mistake: we're already paying indirectly for health care for those who receive health care in extremis, and for care they can't pay for. It raises health care bills - how else is a provider to stay open when the provider cares for 100 patients but only gets paid for 95? The provider still has the expenses of all 100 patients. If the provider has to absorb too much, the provider has to stop; and then no one gets care. The differences get made up in higher premium payments for insurance and higher taxes for government-supported health services. We’re already paying; but there is little system or transparency in the process. We’re paying, but it’s hard to know how, where, or how much. Wouldn’t it be better to have a clearer, more systematic way of addressing these needs?

Why, then, involve government? More specifically, why use tax money? To spread the expenses as widely as possible. That’s what insurance companies do: to reduce premiums they encourage groups to contract, and the larger the group the lower the premiums. However, just government bodies are accountable to the greatest number of people, they also represent the greatest number of people, the largest actuarial pool. The group of “all taxpayers” is the largest possible group across which to spread the expenses – much larger than “all employed,” much less “all well-employed.” Spreading the expenses among the widest pool should be a significant step in controlling how quickly each individual’s contribution would increase.

So, why not seek such public/private partnerships in providing universal access to and coverage for health care? The experiments in coverage in Massachusetts and California do involve both public and private concerns; although some aspects of those plans don't really look like "partnerships." While there are concerns raised regularly about following the British model, there are programs in other nations that do involve public and private participation in providing coverage for all their citizens. We have shown great creativity in health care research and technology, and in business entrepreneurship; and often those have involved public/private partnerships. Why not bring that energy and that creativity to providing access to and reimbursement for health care for all? It makes good sense for public health (and so, among other things, homeland security) and for expenses (and so, among other things, for business). It just makes sense.